Perspectives of Clinicians, Staff, and Veterans in Transitioning Veterans from non-VA Hospitals to Primary Care in a Single VA Healthcare System
BACKGROUND: Veterans with healthcare needs utilize both Veterans Health Administration (VA) and non-VA hospitals. These dual-use veterans are at high risk of adverse outcomes due to the lack of coordination for safe transitions.
OBJECTIVES: The aim of this study was to understand the barriers and facilitators to providing high-quality continuum of care for veterans transitioning from non-VA hospitals to the VA primary care setting.
DESIGN: Guided by the practical robust implementation and sustainability model (PRISM) and the ideal transitions of care, we conducted a qualitative assessment using semi-structured interviews with clinicians, staff, and patients.
SETTING: This study was conducted at a single urban VA medical center and two non-VA hospitals.
PARTICIPANTS: A total of 70 participants, including 52 clinicians and staff (23 VA and 29 non-VA) involved in patient transition and 18 veterans recently discharged from non-VA hospitals, were included in this study.
APPROACH: Data were analyzed using a conventional content analysis and managed in Atlas.ti (Berlin, Germany).
RESULTS: Four major themes emerged where participants consistently discussed that transitions were delayed when they were not able to (1) identify patients as veterans and notify VA primary care of discharge, (2) transfer non-VA hospital medical records to VA primary care, (3) obtain follow-up care appointments with VA primary care, and (4) write VA formulary medications for veterans that they could fill at VA pharmacies. Participants also discussed factors involved in smooth transition and recommendations to improve care coordination.
CONCLUSIONS: All participants perceived the current transition-of-care process across healthcare systems to be inefficient. Efforts to improve quality and safety in transitional care should address the challenges clinicians and patients experience when transitioning from non-VA hospitals to VA primary care.
© 2020 Society of Hospital Medicine
RESULTS
We conducted a total of 70 interviews with 23 VA and 29 non-VA hospital clinicians and staff and 18 veterans (Table 1). Overall, we found that there was no standardized process for transitioning veterans across healthcare delivery systems. Participants reported that transitions were often inefficient when non-VA hospitals could not (1) identify patients as veterans and notify VA primary care of discharge; (2) transfer non-VA hospital medical records to VA primary care; (3) obtain follow-up care appointments with VA primary care; and (4) write VA formulary medications for veterans to fill at VA pharmacies. In addition, participants discussed about facilitators and suggestions to overcome these inefficiencies and improve transitional care (Table2). We mapped the identified barriers as well as the suggestions for improvement to the PRISM and the Ideal Transitions of Care Bridge domains (Table 3).
Unable to Identify Patients as Veterans and Notify VA Primary Care of Discharge
VA and non-VA participants reported difficulty in communicating about veterans’ hospitalizations and discharge follow-up needs across systems. Non-VA clinicians referenced difficulty in identifying patients as veterans to communicate with VA, except in instances where the VA is a payor, while VA providers described feeling largely uninformed of the veterans non-VA hospitalization. For non-VA clinicians, the lack of a systematic method for veteran identification often left them to inadvertently identify veteran status by asking about their primary care clinicians and insurance and even through an offhanded comment made by the veteran. If a veteran was identified, non-VA clinicians described being uncertain about the best way to notify VA primary care of the patient’s impending discharge. Veterans described instances of the non-VA hospital knowing their veteran status upon admission, but accounts varied on whether the non-VA hospital notified the VA primary care of their hospitalization (Table 2, Theme 1).
Unable to Transfer Non-VA Hospital Medical Records to VA Primary Care
VA clinicians discussed about the challenges associated with obtaining the veteran’s medical record from the non-VA hospitals, and when it was received, it was often incomplete information and significantly delayed. They described relying on the veteran’s description of the care received, which was not complete or accurate information needed to make clinical judgment or coordinate follow-up care. Non-VA clinicians mentioned about trying several methods for transferring the medical record to VA primary care, including discharge summary via electronic system and sometimes solely relying on patients to deliver discharge paperwork to their primary care clinicians. In instances where non-VA hospitals sent discharge paperwork to VA, there was no way for non-VA hospitals to verify whether the faxed electronic medical record was received by the VA hospital. Most of the veterans discussed receiving written postdischarge instructions to take to their VA primary care clinicians; however, they were unsure whether the VA primary care received their medical record or any other information from the non-VA hospital (Table 2, Theme 2).
Unable to Obtain Follow-Up Care Appointments with VA Primary Care
All participants described how difficult it was to obtain a follow-up appointment for veterans with VA primary care. This often resulted in delayed follow-up care. VA clinicians also shared that a non-VA hospitalization can be the impetus for a veteran to seek care at the VA for the very first time. Once eligibility is determined, the veteran is assigned a VA primary care clinician. This process may take up to six weeks, and in the meantime, the veteran is scheduled in VA urgent care for immediate postdischarge care. This lag in primary care assignment creates delayed and fragmented care (Table 2, Theme 3).
